Review Question - QID 4487

The above clinical scenario shows acute postoperative fibular malrotation and tibiofibular syndesmotic malreduction. Restoration of the proper syndesmotic relationship involves regaining fibular length as well as reestablishing correct rotation and position of the fibula relative to the tibia. In addition, removal of interposed tissue (deltoid ligament) in the medial joint space may be necessary. However, deltoid reconstruction is not routinely required.

Syndesmosis screw fixation in ankle fractures with syndesmotic disruption is indicated if there is residual or dynamic instability with stress testing of the tibiofibular joint after fixation of the fibula. Syndesmotic screws are commonly maintained in place for at least 12 weeks before removal, if necessary or desired. Controversy exists over use of 1 or 2 screws, screw size, and purchase of 3 or 4 cortices.

Gardner et al. compared radiographic measurements vs CT scans to assess reduction of the tibiofibular syndesmosis in ankle fractures. They found CT was better able to detect syndesmotic malreduction. Although they did not seek to correlate this with functional outcomes, they recommended heightened vigilance for assessing accurate syndesmosis reduction.

Zalavras et al. performed a review on ankle syndesmotic injuries. In their review, they highlight that syndesmotic injuries may occur in isolation or may be associated with ankle fractures. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. They recommend stress testing for detecting syndesmotic instability with fixation of the syndesmosis when evidence of a diastasis is present.

Figures A and B show an ankle fracture treated with ORIF and syndesmotic repair, with syndesmotic and fibular malreduction.

Incorrect Answers:
Answer 1&5: Would not address the current syndesmotic malreduction which should be addressed.
Answer 2: Would not address the syndesmotic malreduction.
Answer 3: Fibular length appears appropriate on AP and lateral radiographs.